The World Breastfeeding Trends Initiative (WBTi) Botswana Assessment Report 2010

The World Breastfeeding Trends Initiative (WBTi) Botswana Assessment Report 2010 Nutrition and Food Control Division Department of Public Health Ministry of Health

LIST OF ABBREVIATIONS BFHI BFHS BNNSS HIV IBFAN IEC ILO IYCF MIS MOH MPC NFCD NGO PMTCT SACU UN UNICEF WABA WBTi WHA WHO Baby Friendly Hospital Initiative Botswana Family Health Survey Botswana National Nutrition Surveillance System Human Immunodeficiency Virus International Baby Food Alliance Network Information Education Communication International Labor Organization Infant and Young Child Feeding Management Information System Ministry of Health Maternity Protection Convention Nutrition and Food Control Division Non Governmental Organization Prevention of Mother To Child Transmission of HIV Southern Africa Customs Union United Nations United Nations Children s Fund World Alliance for Breastfeeding Action World Breastfeeding Trends Initiative World Health Assembly World Health Organization Page 2

BACKGROUND The World Breastfeeding Trends Initiative (WBTi) is an Asia initiative monitoring and evaluation tool linked to International Baby Foods Alliance Network (IBFAN) and World Alliance for Breastfeeding Action (WABA) initiative to improve child and maternal survival. It uses an adopted World Health Organization (WHO) monitoring tool that was introduced together with the Global Strategy for its monitoring in 2003. The initiative encourages country actions for documenting the state of implementation of the Global Strategy on Infant and Young Child Feeding and following up the trends of breastfeeding and progress in programme over time. IBFAN and WABA decided to adopt this WBTi as a tool to monitor the progress of the Global breastfeeding Initiative for Child Survival, whose implementation is based on the Global Strategy. The World Health Assembly (WHA) adopted the Global Strategy for Infant and Young Child Feeding (IYCF) in May 2002 and the UNICEF Executive Board in September 2002 endorsed it. The Global Strategy targets to achieve optimal Infant and Young Child Feeding and improve IYCF practices at the national level to contribute to the prevention of child malnutrition and reduce infant and young child morbidity and mortality; which are critical in Botswana. The Botswana Government through Ministry of Health (Nutrition and Food Control Division) carried out an assessment of the status of the implementation of the Global Strategy using the WBTi tool in order to document the existing gaps in feeding practices, policy and programs. This is a report of the assessment which is also an attempt towards having a road map and action plan for Botswana. In addition, the assessment report will contribute to the evaluation of the 2005-2010 National Plan of Action of Nutrition and define priorities in the area of Infant and Young Child Feeding for the next National Plan of Action for Nutrition. OBJECTIVES OF THE WBTi To find out achievements and gaps in Botswana s existing policy, program and practices in reference to Infant and Young Child Feeding To build a consensus among all the partners METHODOLOGY The WBTi assessment process is, action oriented, brings people together, enables consensus and commitment building, demonstrates achievements and gaps and helps improve programmes efficacy. The WBTi assessment involves three-phase process: Phase 1: The first phase involves initiating a national assessment of the implementation of the Global Strategy. It guides countries and regions to document gaps in existing practices, policies and programmes. This is done based on national documentation by involving multiple partners. Their analysis and the process itself bring governments and other civil society partners together to analyze the situation in the country and find out gaps. The gaps identified are used for developing recommendations for priority action for advocacy and action. The WBTi thus helps in establishment of a practical baseline demonstrating to programme planners, policy makers where improvements are needed to meet the aims and objectives of the Global Strategy. It assists in formulating plans of action that are effective to improve infant and young child feeding practices and guide allocation of resources. It works as a consensus building process and helps to prioritize actions. The initiative thus can impact on policy at the country level, leading to action that would result in better practices. Phase 2: During this phase, WBTi uses the findings of phase 1 to score, rate, grade and rank each country or region based on IBFAN Asia's Guidelines for WBTi thus building some healthy competition among the countries in the region or among regions. Phase 3: In the third phase, WBTi calls for repetition of the assessment after 3-5 years to analyze trends in programmes and practices as well as overall breastfeeding rates in a country, to report on programmes Page 3

and identify areas still needing improvement. This repetition can be also used to study the impact of a particular intervention over a period of time. The WBTi focus is based on a wide range of indicators (15), which provide an impartial global view of key factors. Each indicator has its specific significance. Part 1 has 5 indicators, based on the WHO tool, dealing with infant feeding practices and Part 2 has 10 indicators dealing with policies and programmes. Once assessment of gaps is carried out and data verified, the data on 15 indicators is fed into the web-based toolkit. Page 4

To achieve phase 1 and phase 2 a two days training workshop was conducted. The training had 29 participants coming from Ministry of Health, Ministry of Local Government, Ministry of Labour and Home Affairs, training and research institutions, non- governmental organizations and UNICEF as per the training workshop participant list (Annex 1). The Ministry of Health s Director of Public Health, Mrs Shenaaz El Halabi welcomed all the participants and highlighted how this workshop was important for the progress of infant and young child feeding in Botswana. In their remarks, IFBAN Regional coordinator, Mrs Joyce Chanetsa and UNICEF Botswana also emphasized on the relevance and importance of the WBTi in the Botswana context. The training workshop objectives were: To orient Botswana Infant and Young Child Feeding stakeholders and partners on the process of the World Breastfeeding Trends Initiative. To share national experience on infant feeding issues with IBFAN Africa team. To produce a WBTi training report. After the presentation of the workshop objectives, MOH IYCF coordinator, Mrs Jacinta Sibiya, made a presentation on the national situation of IYCF in Botswana. This presentation was then followed by two presentations by IBFAN Africa, one on the regional trends on IYCF and the second one to introduce the WBTi to participants and the methodology of the assessment and the indicators. Each of the 15 indicators has a key question that needs to be investigated and a list of key criteria as a subset of questions to consider in identifying achievements and areas needing improvement, with guidelines for scoring, rating and grading how well the country is doing. Two sets of indicators were monitored as follow: Part 1: Infant and Young Child Feeding Practices in Part I ask for specific numerical data on each practice based on data from random household survey that is national in scope. Part 2: A set of criteria has been developed for each target based on the Innocenti Declaration of 2005, which set 5 additional targets. For each indicator, there is a subset of questions. Answers can lead to identifying achievements and gaps. Scoring, colour-rating and grading is done for each individual indicator. The toolkit objectively quantifies the data to provide a colour- rating and grading i.e. 'Red' or 'Grade D', Yellow or 'Grade C', Blue or 'Grade B' and Green or Grade A. INDICATORS Part 1 IYCF practices 1. Percentage of babies breastfed within one hour of birth 2. Percentage of babies 0<6 months of age exclusively breastfed in the last 24 hours 3. Babies are breastfed for a median duration of how many months 4. Percentage of breastfed babies less than 6 months old receiving other foods or drink from bottles 5. Percentage of breastfed babies receiving complementary foods at 6-9monthsof age Part 2 Policy and Programmes 6. National Policy, Programme and Coordination 7. Baby Friendly Hospital Initiative (Ten Steps to Successful Breastfeeding) 8. Implementation of the International Code 9. Maternity Protection 10. Health and Nutrition Care 11. Community Outreach 12. Information Support 13. Infant Feeding and HIV 14. Infant Feeding During Emergencies 15. Monitoring and Evaluation After the presentation session, three groups were formed to review the available data and discuss the situation in Botswana, the gaps and make recommendations. Group 1 worked on indicators 1 to 5, group 2 and 3 worked respectively on indicators 6-10 and 11-15. Each group then made a presentation of their work in plenary for discussion. Page 5

At the end of the two days workshop, participants were tasked to fine tune their work. Representatives of each group then met for three days between May and July 2010 to discuss group inputs and generate both the WBti report and the report card. The draft report and report card were then reviewed by participants from the WBTi training (conducted in May 2010) and finalized on August 3 rd, 2010. Page 6

Indicator 1: Early Initiation of Breastfeeding Key question: Percentage of babies breastfed within one hour of birth Guideline: Indicator 1 Initiation of Breastfeeding (within 1 hour) WHO s Key to rating (%) Existing Status % IBFAN Asia Guidelines for WBTi IBFAN score Grading 0-29 3 Red D 30-49 40.0% 6 Yellow C 50-89 9 Blue B 90-100 10 Green A Source of data: Central Statistics Office. (2009). Botswana Family Health Survey IV, 2007. Government Printers, Gaborone, Botswana Summary Comments: There are numerous opportunities for the improvement of early breastfeeding initiation practice in Botswana before and after delivery since most mothers attend ANC services (94.1%), most mothers gave birth in a health facility (93.8%) and the delivery process is attended by skilled health workers in most cases (94.6%). Indicator 2: Exclusive breastfeeding for the first six months Key question: Percentage of babies 0<6 months of age exclusively breastfed in the last 24 hours? Guideline: Indicator 2 Exclusive Breastfeeding (for first 6 months) WHO s Key to rating % Existing Status % IBFAN Asia Guidelines for WBTi IBFAN score Colourrating Colourrating Grading 0-11 3 Red D 12-49 20.3% 6 Yellow C 50-89 9 Blue B 90-100 10 Green A Source of data: Central Statistics Office. (2009). Botswana Family Health Survey IV, 2007. Government Printers, Gaborone, Botswana Page 7

Indicator 3: Median duration of breastfeeding Key question: Babies are breastfed for a median duration of how many months? Guideline: Indicator 3 Median Duration of Breastfeeding (data available as mean only) WHO s Key to rating Existing Status IBFAN Asia Guidelines for WBTi IBFAN score Grading 0-17 Months 12.5 3 Red D 18-20 6 Yellow C 21-22 9 Blue B 23-24 10 Green A Source of data: Central Statistics Office. (2009). Botswana Family Health Survey IV, 2007. Government Printers, Gaborone, Botswana Indicator 4: Bottle feeding Key question: What percentage of breastfed babies less than 6 months old receives other foods or drinks from bottles? Guideline: Indicator 4 Bottle Feeding (<6 months) WHO s Key to rating Existing Status % IBFAN Asia Guidelines for WBTi IBFAN score Colourrating Colourrating Grading 30-100% 3 Red D 5-29% 6 Yellow C 3-4% 9 Blue B 0-2% 10 Green A Summary Comments: No data available Recommendation : include indicator in planned studies (core welfare indicator surveys- CSO) Page 8

Indicator 5: Complementary feeding Key question: Percentage of breastfed babies receiving complementary foods at 6-9 months of age? Guideline: Indicator 5 Complementary Feeding (6-9 months) WHO s Key to rating % Existing Status % IBFAN Asia Guidelines for WBTi IBFAN score Colourrating Grading 0-59 45.5% 3 Red D 60-79 6 Yellow C 80-94 9 Blue B 95-100 10 Green A Source of data: Central Statistics Office. (2009). Botswana Family Health Survey IV, 2007. Government Printers, Gaborone, Botswana Page 9

Indicator 6: National Policy, Programme and Coordination Key Question: Is there a national infant and young child feeding/breastfeeding policy that protects, promotes and supports optimal infant and young child feeding and the policy is supported by a government programme? Is there a mechanism to coordinate like National Infant and Young Child Feeding Committee and Coordinator? Criteria of Indicator 6 Scoring Results Check any one 6.1) A national Infant and Young Child Feeding/Breastfeeding policy has been officially adopted/approved by the government 6.2) The policy promotes exclusive breastfeeding for the first six months, complementary feeding to be started after six months and continued breastfeeding up to 2 years and beyond. 6.3) A National Plan of Action has been developed with the policy 2 2 2 6.4) The plan is adequately funded 1 6.5) There is a National Breastfeeding Committee 1 6.6) The National Breastfeeding (Infant and Young Child Feeding) Committee meets and reviews on a regular basis 6.7) The National Breastfeeding (Infant and Young Child Feeding) Committee links with all other sectors like health, nutrition, information etc., effectively 6.8) Breastfeeding Committee is headed by a coordinator with clear terms of reference 1 0.5 0.5 Total Score 3.5/ 10 Information and Sources Used: Draft Botswana National Policy on Infant and Young Child Feeding, 2009 National Plan of Action for Nutrition 2005-2010 Term of References of IYCF National Coordinator Expert opinion Gaps: The Botswana National Policy on Infant and Young Child Feeding, 2009 is in a draft status. As the Policy has not yet been approved, there is no Infant and Young Child Feeding strategic plan with set targets and budget. Such strategic plan would provide details on five actions areas of a comprehensive strategy, i.e. 1) National level from Policy, legislation, budgeting and M&E, 2) Health system level actions, 3) Community based actions, 4) Communication for behaviour and social change and 5) IYCF in difficult circumstances (HIV and emergencies). Meanwhile the 2005-2010 National Plan of Action for Nutrition touches on two (health system actions and IYCF in HIV) of the five action areas of a comprehensive IYCF programming. A National breastfeeding committee was established, but currently not active. Page 10

Recommendations: Review of current IYCF draft Policy in light of MOH s decision on the 2009 WHO Recommendations on HIV and infant feeding. Advocate for approval of the draft IYCF policy. Develop a comprehensive IYCF strategy. Revive the National Breastfeeding committee and review its TORs and name and composition. Update the national coordinator and secretariat TORs accordingly. Page 11

Indicator 7: Baby Friendly Hospital Initiative (Ten Steps to Successful Breastfeeding) Key Question: 7A) What percentage of hospitals and maternity facilities that provide maternity services have been designated Baby Friendly based on the global or national criteria? 7B) What is the skilled training inputs and sustainability of BFHI? 7C) What is the quality of BFHI program implementation? 7A) Quantitative 7.1) What percentage of hospitals and maternity facilities that provide maternity services have been designated Baby Friendly based on the global or national criteria? 0 out of 34 hospitals (0%) Criteria Score Results 0 0 Check any one 0.1-7% 1 8 49% 2 50 89% 3 90-100% 4 Rating on BFHI quantitative achievements: 0/4 7B) Qualitative 7.2) What is the skilled training inputs and sustainability of BFHI? 0 out of 34 (0%) BFHI designated hospitals that have been certified after a minimum recommended training of 18 hours for all its staff working in maternity services Criteria Score Results 0 0 0.1-25% 1 26-50% 1.5 51 75% 2.5 75% and more 3.5 Check any one Total Score 0/3.5 Page 12

Qualitative 7C) What is the quality of BFHI program implementation? Criteria Score Results 7.3) BFHI programme relies on training of health.5 workers 7.4) A standard monitoring system is in place.5 Check that apply 7.5) An assessment system relies on interviews of mothers 7.6) Reassessment systems have been incorporated in national plans 7.7) There is a time-bound program to increase the number of BFHI institutions in the country Total Score 2.5/2.5 Total Score 7A, 7B and 7C 2.5/10.5.5.5 Information and Sources Used: National Plan of Action of Nutrition 2005-2010 Gaps: The training of health workers on BMFHI is not up to scale yet and frequent staff turn-over (for those who have been trained) prevent proper implementation of training gain at district level. BMFHI training has not been integrated into the pre-service curriculum of health workers. Inadequate ownership and monitoring of BMFHI at health facility level. The assessment of the BMFHI quality of hospitals and maternity facilities is very limited as no BMFHI assessment has been carried out in the last four years. No review/ monitoring of BMFHI implementation(effectiveness) Recommendations: Integrate BMFHI into the pre-service training curriculum of health workers. Train all hospitals to achieve BFHI status Revamp BMFHI as follow: o Continuously assess hospitals and maternity facilities within 3 years o Develop an advocacy package for resource mobilization o Develop a BMFHI training plan (pre and in service) in integration with existing training package designed for health workers o Integrate BMFHI as an indicator of health facility performance report o Develop and implement a monitoring and evaluation plan Page 13

Indicator 8: Implementation of the International Code Key Question: Are the International Code of Marketing of Breastmilk Substitutes and subsequent WHA resolution given effect and implemented? Has any new action been taken to give effect to the provisions of the Code? Criteria Scoring Results Check those apply. 8.1) No action taken 0 8.2) The best approach is being studied 1 8.3) National breastfeeding policy incorporating the Code in full or in part but not legally binding and therefore unenforceable 8.4) National measures (to take into account measures other than law), awaiting final approval 8.5) Administrative directive/circular implementing the Code in full or in part in health facilities with administrative sanctions 2 3 4 8.6) Some articles of the Code as a voluntary measure 5 8.7) Code as a voluntary measure 6 8.8) Some articles of the Code as law 7 8.9) All articles of the Code as law 8 8.10) All articles of the Code as law, monitored and enforced 10 Total Score: 8/10 Information and Sources Used: Marketing of foods for infants and young children regulations, 2005 Final internal evaluation of the Interagency Group on Breastfeeding Monitoring (IGBM), 2010 Gaps/challenges: Some of the articles of the law covering food labelling repealed. All stakeholders have not been trained on the Botswana Regulations and code monitors are not covering all districts. Resistance by some baby food manufacturers to comply to all provisions of the Botswana regulations Repeated violations of the Botswana regulations by baby foods manufacturers Absence of regulatory mechanisms that would safe guard public private partnership and protect established laws and regulations in the best interests of children and the public sector. Botswana is the only country within the Southern Africa Customs Union (SACU) to have a regulation on the marketing of baby foods in place, which hinders compliance with the Botswana Regulations at entry points. Page 14

Recommendations: Reinstate the repealed articles Expand the training on Botswana s regulations to health workers, managers and decision makers. Efforts should be made to have a continuous program on the sensitization of the Public on the law Strengthen the enforcement of code monitoring at implementers level. Conduct high level sensitization and advocacy on the Botswana regulations. Re-activate a multi-sectoral code monitoring working group to provide regular update of code monitoring issues and progress and technical advice to MOH s National Food Control Board. Regional and national level efforts to sensitize other SACU member countries to have their draft code regulations passed. Page 15

Indicator 9: Maternity Protection Key Question: Is there legislation and are there other measures (policies, regulations, practices) that meet or go beyond the International Labor Organization (ILO) standards for protecting and supporting breastfeeding for mothers, including those working mothers in the informal sector? Criteria Score Results 9.1) Women covered by the national legislation are allowed the following weeks of paid maternity leave a. Any leave less than 14 weeks 0.5 b. 14 to 17weeks 1 c. 18 to 25 weeks 1.5 d. 26 weeks or more 2 Check that apply 9.2) Women covered by the national legislation are allowed at least one breastfeeding break or reduction of work hours daily. 1 a. Unpaid break 0.5 b. Paid break 1 9.3) Legislation obliges private sector employers of women in the country to give at least 14 weeks paid maternity leave and paid nursing breaks. 9.4) There is provision in national legislation that provides for work site accommodation for breastfeeding and/or childcare in work places in the formal sector. 9.5) Women in informal/unorganized and agriculture sector are: 1 1 1 a. accorded some protective measures 0.5 b. accorded the same protection as women working in the formal sector 9.6) a. Information about maternity protection laws, regulations, or policies is made available to workers b. There is a system for monitoring compliance and a way for workers to complain if their entitlements are not provided. 9.7) Paternity leave is granted in public sector for at least 3 days. 9.8) Paternity leave is granted in the private sector for at least 3 days. 9.9) There is legislation providing health protection for pregnant and breastfeeding workers and the legislation 1 0.5 0.5 0.5 0.5 0.5 Page 16

provides that they are informed about hazardous conditions in the workplace and provided alternative work at the same wage until they are no longer pregnant or breastfeeding. 9.10) There is legislation prohibiting employment discrimination and assuring job protection for women workers during breastfeeding period. 9.11) ILO MPC No 183 has been ratified, or the country has a national law equal to or stronger than C183. 9.12) The ILO MPC No 183 has been enacted, or the country has enacted provisions equal to or stronger than C183. Total Score: 2.5/10 0.5 0.5 0.5 Information and Source Used: Circular DP.5/3 1(35) of June 1982 from Department of Public Service Management (DPSM) Comments: The national legislation only covers for women in the Public Sector. Gaps: No legislation obliging private sectors/informal sectors to give women paid martenity leave Paternity leave not granted in both public and private sector. ILO MPC No 183 has not been fully adopted. There is no infrastructural provision for breastfeeding in the workplace. Recommendations: Advocate for the ratification of ILO MPC No 183, Provide breastfeeding facilities in the workplace (breastfeeding friendly spaces/corners). Page 17

Indicator 10: Health and Nutrition Care System Key Question: Do care providers in these systems undergo skills training, and do their pre-service education curriculum support optimal infant and young child feeding; do these services support mother and breastfeeding friendly birth practices, do the policies of health care services support mothers and children, and whether health workers responsibilities to Code are in place? Criteria Results Check that apply Adequate Inadequate No Reference 10.1) A review of health provider schools and pre-service education programmes in the country 1 indicates that infant and young child feeding curricula or session plans are adequate/inadequate 10.2) Standards and guidelines for mother-friendly childbirth procedures and support have been developed and disseminated to all facilities and personnel providing maternity care. 10.3) There are in-service training programmes providing knowledge and skills related to infant and young child feeding for relevant health/nutrition care providers. 2 10.4) Health workers are trained with responsibility towards Code implementation as a key input. 1 0.5 0 10.5) Infant feeding-related content and skills are integrated, as appropriate, into training programmes focusing on relevant topics (diarrhoeal disease, acute respiratory infection, IMCI, well-child care, family planning, nutrition, the Code, HIV/AIDS, etc.) 1 0.5 0 10.6) These in-service training programmes are being 1 0.5 0 provided throughout the country. 3 10.7) Child health policies provide for mothers and babies to stay together when one of them is sick 1 0.5 0 Total Score: 6/10 Information and Sources Used: In-service health workers curriculum 1 Types of schools and education programmes that should have curricula related to infant and young child feeding may vary from country to country. Which departments within various schools are responsible for teaching various topics may also vary. The assessment team should decide which schools and departments are most essential to include in the review, with guidance from educational experts on infant and young child feeding, as necessary. 2 The types of health providers that should receive training may vary from country to country, but should include providers that care for mothers and children in fields such as medicine, nursing, midwifery, nutrition and public health. 3 Training programmes can be considered to be provided throughout the country if there is at least one training programme in each region or province or similar jurisdiction. Page 18

Comments: (10.7) only applies when the child is sick and only if the facility can accommodate the mother. Gaps: IYCF not adequately infused in health workers pre-service curriculum. Code implementation and monitoring is not a key input in health workers daily routine. Standards and guidelines not adequately disseminated to all facilities and personnel providing martenity care Coverage of In-service trainings programmes are limited due to inadequate funds IYCF competing with other public health issues Recommendations: Revise health workers curriculum for IYCF skills improvement. Train health workers on code implementation and monitoring. Trainings need to be adequately funded (both at district and national level) Scale up trainings on IYCF/BMFHI Page 19

Indicator 11: Mother Support and Community Outreach Key Question: Are there mother support and community outreach systems in place to protect, promote and support optimal infant and young child feeding? Criteria 11.1) All pregnant women have access to community-based support systems and services on infant and young child feeding. 11.2) All women have access to support for infant and young child feeding after birth. 11.3) Infant and young child feeding support services have national coverage. Results Check that apply Yes To some degree No 11.4) Community-based support services for the pregnant and breastfeeding woman are integrated into an overall infant and young child health and development strategy (inter-sectoral and intra-sectoral. 11.5) Community-based volunteers and health workers possess correct information and are trained in counselling and listening skills for infant and young child feeding. Total Score: 5/10 Information and Sources Used: Expert opinion from health care workers at community level involved in IYCF issues Gaps: Inadequate (limited coverage) mother support and community outreach systems to protect, promote and support optimal infant and young child feeding practices. Limited integration and collaboration between health care services and community-based ones. Resources limitation. Recommendations: Integrate/align health facility-based and community based infant and young child feeding services. Strengthen the coordination and expand community-based IYCF support systems to mothers through multisectoral collaboration. Increase collaboration between MOH and civil society organisations Page 20

Indicator 12: Information Support Criteria 12.1) There is a comprehensive national IEC strategy for improving infant and young child feeding. 12.2) IEC programmes (e.g. World Breastfeeding Week) that include infant and young child feeding are being actively implemented at local levels 12.3) Individual counselling and group education services related to infant and young child feeding are available within the health/nutrition care system or through community outreach. 12.4) The content of IEC messages is technically correct, sound, based on national or international guidelines. Yes Results Check that apply To some degree No 12.5) A national IEC campaign or programme 4 using electronic and print media and activities has channelled messages on infant and young child feeding to targeted audiences in the last 12 months. Total Score: 5/10 Information and Sources Used: Expert opinion from health care workers involved and health education specilaist Gaps: There is no comprehensive IYCF IEC strategy in place. Lack of collaboration and coordination of implementing partners leading to isolation and duplication. Recommendations: Develop an IYCF comprehensive IEC strategy. Develop and implement coordination mechanisms for IYCF interventions Rolling out Accelerated Child Survival Development 4 An IEC campaign or programme is considered national if its messages can be received by the target audience in all major geographic or political units in the country (e.g., regions or districts). Page 21

Indicator 13: Infant Feeding and HIV Key Question: Are policies and programmes in place to ensure that HIV positive mothers are informed about the risks and benefits of different infant feeding options and supported in carrying out their infant feeding decisions? Criteria 13.1) The country has a comprehensive policy on infant and young child feeding that includes infant feeding and HIV 13.2) The infant feeding and HIV policy gives effect to the International Code/ National Legislation 13.3) Health staff and community workers receive training on HIV and infant feeding policies, the risks associated with various feeding options for infants of HIV-positive mothers and how to provide counselling and support. 13.4) Voluntary and Confidential Counselling and Testing (VCCT) is available and offered routinely to couples who are considering pregnancy and to pregnant women and their partners. 13.5) Infant feeding counselling in line with current international recommendations and locally appropriate is provided to HIV positive mothers. 13.6) Mothers are supported in making their infant feeding decisions with further counselling and follow-up to make implementation of these decisions as safe as possible. 13.7) Special efforts are made to counter misinformation on HIV and infant feeding and to promote, protect and support 6 months of exclusive breastfeeding and continued breastfeeding in the general population. 13.8) On-going monitoring is in place to determine the effects of interventions to prevent HIV transmission through breastfeeding on infant feeding practices and overall health outcomes for mothers and infants, including those who are HIV negative or of unknown status. 13.9) The Baby-friendly Hospital Initiative incorporates provision of guidance to hospital administrators and staff in settings with high HIV prevalence on how to assess the needs and provide support for HIV positive mothers. Yes Results Check that apply To some No degree 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 1 0.5 0 Total Score: 5/10 Page 22

Information and Sources Used: Draft Botswana National Policy on Infant and Young Child Feeding, 2009 PMTCT guidelines and training manuals Gaps: Health workers skills in infant feeding counselling and support in HIV are sub-optimal. The support provided to mothers to better implement their infant feeding choice is not adequate. The monitoring of IYCF counselling and support is inadequate. Spill over of infant formula feeding from PMTCT mothers to non PMTCT mothers is still a challenge Recommendations: Improve health workers and lay counsellors skills to better support infant feeding practices. Strengthen the monitoring of the nutrition services (counselling, care and support) to infant and young children born from HIV infected mothers. Special efforts to be put in place to counteract misinformation about HIV especially to the public Involve politicians and local leaders on information dissemination Page 23

Indicator 14: Infant Feeding during Emergencies Key Question: Are appropriate policies and programmes in place to ensure that mothers, infants and children will be provided adequate protection and support for appropriate feeding during emergencies? Criteria 14.1) The country has a comprehensive policy on infant and young child feeding that includes infant feeding in emergencies 14.2) Person(s) tasked with responsibility for national coordination with the UN, donors, military and NGOs regarding infant and young child feeding in emergency situations have been appointed Yes Results Check that apply To some No degree 14.3) An emergency preparedness plan to undertake activities to ensure exclusive breastfeeding and appropriate complementary feeding and to minimize the risk of artificial feeding has been developed 14.4) Resources identified for implementation of the plan during emergencies 14.5) Appropriate teaching material on infant and young child feeding in emergencies has been integrated into pre-service and in-service training for emergency management and relevant health care personnel. Total Score: 1/10 Information and Sources Used: Draft Botswana National Policy on Infant and Young Child Feeding, 2009 Gaps: Lack of protection and support for appropriate infant and young child feeding before and during emergencies (i.e. floods) There is no infant feeding task team that will provide infant feeding technical support to the Disaster Management Committee Current emergency preparedness plan have no detailed nutrition/infant feeding in emergencies components Health workers pre-service and in-service curriculum do not have infant feeding in emergencies components Recommendations: Set-up an infant feeding in emergencies task team. Integrate infant and young child feeding emergency package in the National Disaster Preparedness strategy. Page 24

Indicator 15: Monitoring and Evaluation Key Question: Are monitoring and evaluation data routinely collected and used to improve infant and young child feeding practices? Criteria 15.1) Monitoring and evaluation components are built into major infant and young child feeding programme activities. Yes Results Check that apply To some No degree 15.2) Monitoring or Management Information System (MIS) data are considered by programme managers in the integrated management process. 15.3) Baseline and follow-up data are collected to measure outcomes for major infant and young child feeding programme activities. 15.4) Evaluation results related to major infant and young child feeding programme activities are reported to key decision-makers 15.5) Monitoring of key infant and young child feeding practices is built into a broader nutritional surveillance and/or health monitoring system or periodic national health surveys. Total Score: 6/10 Information and Sources Used: Child Welfare Clinic Card Botswana National Nutrition Surveillance System (BNNSS) forms Botswana Family Health Survey (BFHS), 2000, 2007 Indicators for assessing infant and young child feeding practices. Part 1-Definitions. WHO 2008 Gaps: No trends analysis on infant and young child feeding practices (with districts disaggregated data) has been performed. Revised set of core and/ or optional indicators are not reflected in national surveys questionnaires. Since the 2001 infant feeding practices assessment in PMTCT and non PMTCT sites, no comprehensive assessment of infant and young child feeding practices has been conducted in Botswana (general population and the PMTCT one). This limits the analysis of the success and challenges in the feeding practices of children (born from HIV infected mothers, mothers of unknown status and mothers known to be HIV uninfected). Recommendations: Conduct secondary analysis of infant and young child feeding data. Integrate the revised infant and young child feeding indicators in national surveys. Page 25

Conduct period assessment of infant and young child feeding practices(time period to be determined in the action plan). This analysis could enable the adaptation of community messages which would fit the local context better. Page 26

CONCLUSIONS AND RECOMMENDATIONS The WBTi assessment process enabled us to take stock of the progress made in Botswana towards the implementation of the Global strategy IYCF and showed that Botswana scored 64.5 points out of 150. The opportunities and challenges in implementing the global strategy in Botswana were identified. More specifically, the WBTi process showed the following key gaps in the implementation of the IYCF global strategy: Draft IYCF Policy is not aligned with the 2009 WHO recommendations No comprehensive IYCF strategy, including communication strategy Low coverage, inadequate implementation and inadequate monitoring of Baby Friendly Hospital Initiative (BFHI) Inadequate mother support and community outreach systems in place to protect, promote and support optimal infant and young child feeding Lack of protection and support for appropriate infant and young child feeding before and during emergencies (e.g. during floods) National maternity policy not in line with the ILO Maternity Protection 183 of Convention 2000 The Botswana WBti report key recommendations follow: Revise Draft IYCF Policy in light of MOH s decision regarding the 2009 WHO infant feeding and HIV guidelines Develop comprehensive IYCF implementation strategy Include the BFHI 10 steps in performance assessment for health facilities Integrate, coordinate and expand community-based IYCF support systems to mothers through multisectoral collaboration Integrate IYCF in emergency package in the National Disaster Preparedness Strategy Advocate for ratification of the ILO Maternity Protection 183 of Convention 2000, including maternity protection for women in the private sector In addition to the finalization of this report, the Botswana team agreed to develop a plan of action based on this report recommendation as a way to make a better use of the overall WBTi assessment process. Page 27

REFERENCES Central Statistics Office. (2009). Botswana Family Health Survey IV, 2007. Government Printers, Gaborone, Botswana Ministry of Health. (2009). Draft Botswana National Policy on Infant and Young Child Feeding, 2009 Ministry of Health. (2005). National Plan of Action for Nutrition 2005-2010 Term of References of IYCF National Coordinator Ministry of Health. Marketing of foods for infants and young children regulations, 2005 Final internal evaluation of the Interagency Group on Breastfeeding Monitoring (IGBM), 2010 Circular DP.5/3 1(35) of June 1982 from Department of Public Service Management (DPSM) In-service health workers curriculum PMTCT guidelines and training manuals Child Welfare Clinic Card Botswana National Nutrition Surveillance System (BNNSS) forms WHO (2008). Indicators for assessing infant and young child feeding practices. Part 1-Definitions. Page 28

List of the partners for the assessment process WORLD BREASRFEEDING TRENDS INITIATIVE TRAINING WORKSHOP FOR BOTSWANA DATE: 06 MAY 1010,GABORONE SUN Name Designation Place of Work telephone Email and mobile 1.Patience P Madabe HOI MOH 3632158 pmadabe@gov.bw 2.Rosinah Pitinyane AHO MOH 3632263 rpitinyane@gov.bw 3.Joyce Gonnetsweng ----- MOH 3632159 gonnetswengj@gmail.com 4.Kenanao Motlhoiwa HOII MOH 3632160 kmotlhoiwa@gov.bw 5.Collen Rannana PMTCT AED 3191956 colleen@aed.org.bw 6.M Galennelwe PHOI MLG 3953810 mgaleemelwe@gov.bw 7.HHT Tarimo PSOI MOH 3632121 htarimo@gov.bw 8.Kentse Marope ----- MOH 3632144 kemarope@gov.bw 9.Kehumile J Modise ----- MOH 3632187 kmodise@gov.bw 10.Judith K Masepe MIDWIFE PMH PNW 3621659 jmasepe@yahoo.com 11.Dikoloti Morewane ----- BOBA 71455245 12.Letlhogonono DIETITIAN TAB 71278004 Letsgab2003@yahoo.com Gabanamotse HOSPITAL 13.Gofaone Mosweu NURSE SSKB CLINIC 74012532 gofaonemosweu@yahoo.co m 14.Maemo Lesiapeto DIETITIAN PMH DIETETICS 72265181 Maemolesia@yahoo.com 15.Elliott Ramooki STATISTICIAN HEALTH STATS.PME 3632429 eramooki@yahoo.com 16.Virginia Mapima SNO NRH 72533120/74 Jablue63@yahoo.com 649936 17.Vaya Ntingane LECTURER HIS (LOBATSE) 18.Rosemary Kobue- Sr RESEARCH NFTRC 71320960 rosemary@naftec.org Lekalake SCIENTIST 19.Segametsi Maruapula LECTURER UNIVERSIT 71962284 Y OF BOTSWANA 20.M. Basheke PHO MOH 72442105 mbasheke@gov.bw 21.Leah Matlala LABOUR LSS/HQ 72911223 OFFICE 22.Lebogang G Mogapi PATHFINDER PATHFINDE 3191816 Gmogape@pathfind.org R 23.Mphoyamodimo ASO MOH 3632134 mmongati@gov.bw Mongati 24.Clifford Motsemme ASO MOH 3632135 cmotsemme@gov.bw 25.Fredrick Mooketsane DATA CLERK MOH 3632159 fmooketsane@gov.bw 26.Patrick Codjia NUTRITION UNICEF 3951909 pcodjia@unicef.org SPECIALIST 27.Panky G Mogomotsi PMTCT MOH 3632318 gpmogomotsi@gov.bw NUTRITIONIS T 28.Anna Makwa AHO MOH 3632160 amakwa@gov.bw 29.J sibiya PHO MOH jsibiya@gov.bw Page 29